Nursing Care During Normal Pregnancy and Developing Fetus PDF

UNIT 3 NURSING CARE DURING NORMAL PREGNANCY AND CARE OF THE DEVELOPING FETUS  2 FERTILIZATION Conception/ Impregnation  3 IMPLANTATION 4 EMBRYONIC AND FETAL 5 STRUCTURES The Decidua or Uterine Lining - “Sloughing...

UNIT 3 NURSING CARE DURING NORMAL PREGNANCY AND CARE OF THE DEVELOPING FETUS  2 FERTILIZATION Conception/ Impregnation  3 IMPLANTATION 4 EMBRYONIC AND FETAL 5 STRUCTURES The Decidua or Uterine Lining - “Sloughing off” - The corpus luteum under the influence of Human Chorionic Gonadotropin causes the uterine endometrium to continue to grow in thickness and vascularity.  6 EMBRYONIC AND FETAL STRUCTURES Chorionic Villi 11th or 12th day- miniature villi reach out from the single layer of cells into the uterine endometrium to begin formation of the placenta. At term, almost 200 such villi will have formed. Syncytiotrophoblast Cytotrophoblast (Langhan’s Layer) EMBRYONIC AND FETAL 7 STRUCTURES The Placenta “pancake” 15 to 20 cm in diameter and 2 to 3 cm in depth Endocrine Function hCG Progesterone Estrogen hPL Human Chorionic Gonadotropin 8 - Maintains the uterine endometrium - Suppresses the maternal immunologic response Progesterone -The hormone that maintain pregnancy, maintains the uterine endometrium throughout pregnancy -Reduce contractility of the uterus -placental production begins at about the 12th week Estrogen -contributes to mammary gland growth -stimulates uterine growth Human Placental Lactogen - Growth promoting and lactogenic - regulates maternal glucose, protein and fat EMBRYONIC AND FETAL 9 STRUCTURES Amniotic Membrane -not only offers support to amniotic fluid but also actually produces the fluid. It also produces a phospholipid that initiates the formation of prostaglandins, which can cause uterine contractions and may be the trigger that initiates labor The Amniotic Fluid At term-800 to 1200 mL Hydramnios (more than 2000 mL in total, or pockets of fluid larger than 8 cm on ultrasound) Oligohydramnios, or a reduction in the amount of amniotic fluid (less than 300 mL in total, or no pocket on ultrasound larger than 1 cm) pH7.2 EMBRYONIC AND FETAL 10 STRUCTURES The Umbilical Cord -formed from the fetal membranes (amnion and chorion) and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta. -one vein and two arteries -transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta -about 53 cm (21 in) in length at term and about 2 cm (3 ⁄4 in) thick. -The bulk of the cord is a gelatinous mucopolysaccharide called Wharton jelly, which gives the cord body and prevents pressure on the vein and arteries that pass through it. The outer surface is covered with amniotic membrane ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS  All organ systems are complete, at least in a rudimentary form, at 8 weeks’ gestation Yolk sac - supply nourishment only until implantation. provide a source of red blood cells until the embryo’s hematopoietic system is mature enough to perform this function (at about the 12th week of intrauterine life). Teratogens-any factor that adversely affects the fertilized ovum, embryo, or fetus, CARDIOVASCULAR SYSTEM 3rd week- the respiratory and digestive tracts exist as a single tube 4th week- septum begins to divide the esophagus from the trachea. At the same time, lung buds appear on the trachea 7th week of life, the diaphragm does not completely divide the thoracic cavity from the abdomen 3 months- Spontaneous respiratory practice movements -Surfactant, a phospholipid substance, formed and excreted by the alveolar cells at about the 24th week of pregnancy. (Lecithin and Sphingomyelin-- 2:1) - decreases alveolar surface tension on expiration, preventing alveolar collapse and improving infant’s ability to maintain respirations in the outside environment RESPIRATORY SYSTEM THE NERVOUS SYSTEM ENDOCTRINE SYSTEM The fetal adrenal glands supply a precursor necessary for estrogen synthesis by the placenta The fetal pancreas produces insulin needed by the fetus (insulin is one of the few substances that does not cross the placenta from the mother to the fetus). The thyroid and parathyroid glands play vital roles in fetal metabolic function and calcium balance.  The gastrointestinal tract is sterile before Digestive System birth. Sucking and swallowing reflexes are not The digestive tract separates from mature until the fetus is at about 32 weeks’ the respiratory tract at about the gestation or weighs 1500 g fourth week of intrauterine life. Enzymes found in saliva that is necessary for Meconium, a collection of cellular digestion of complex starches and fat are not wastes, bile, fats, mucoproteins, yet mature until few months after birth mucopolysaccharides, and portions of the vernix caseosa, the The liver is active throughout the pregnancy lubricating substance that forms on but is still not mature. the fetal skin, accumulates in the intestines as early as the 16th week  REPRODUCTIVE SYSTEM MUSCULOSKELETAL A child’s sex is determined at the moment of A fetus can be seen to move on an conception by a spermatozoon carrying an X or a Y chromosome and can be ascertained as early as ultrasound as early as the 11th week, 8 weeks by chromosomal analysis although the woman usually does not feel this movement (quickening) The testes first form in the abdominal cavity and until almost 20 weeks of gestation. do not descend into the scrotal sac until the 34th to 38th week.  URINARY SYSTEM Urine is formed by the 12th week and is excreted into the Integumentary System amniotic fluid by the 16th week The skin of a fetus appears thin and almost of gestation. translucent until subcutaneous fat begins to be deposited at about 36 weeks. Early in the embryonic stage of Skin is covered by soft downy hairs (lanugo) urinary system development, and vernix caseosa, a cream cheese-like substance the bladder extends as high as which is important for lubrication and for keeping the the umbilical region skin from macerating in utero. patent urachus,  IMMUNE SYSTEM Immunoglobulin G (IgG) (20th week- 24th week ) to give a fetus temporary passive immunity against diseases for which the mother has antibodies. e.g poliomyelitis, rubella (German measles), rubeola (regular measles), diphtheria, tetanus, infectious parotitis (mumps), hepatitis B, and pertussis (whooping cough MILESTONES OF FETAL GROWTH AND DEVELOPMENT End of 4th Gestational Week At the end of the fourth week of gestation, the human embryo is a group of rapidly growing cells but does not yet resemble a human being. Length: 0.75–1 cm Weight: 400 mg The spinal cord is formed and fused at the midpoint. Lateral wings that will form the body are folded forward to fuse at the midline. The head folds forward and becomes prominent, representing about one-third of the entire structure. The back is bent so that the head almost touches the tip of the tail. The rudimentary heart appears as a prominent bulge on the anterior surface End of 8th Gestational Week Length: 2.5 cm (1 in) Weight: 20 g Organogenesis is complete. The heart, with a septum and valves, is beating rhythmically. Facial features are definitely discernible. Arms and legs have developed. External genitalia are forming, but sex is not yet distinguishable by simple observation. The primitive tail is regressing. The abdomen bulges forward because the fetal intestine is growing so rapidly. An ultrasound shows a gestational sac, diagnostic of pregnancy (Fig. 9.8). End of 12th Gestational Week (First Trimester) Length: 7–8 cm Weight: 45 g Nail beds are forming on fingers and toes. Spontaneous movements are possible, although they are usually too faint to be felt by the mother. Some reflexes, such as the Babinski reflex, are present. Bone ossification centers begin to form. Tooth buds are present. Sex is distinguishable by outward appearance. Urine secretion begins but may not yet be evident in amniotic fluid. The heartbeat is audible through Doppler technology. End of 16th Gestational Week Length: 10–17 cm Weight: 55–120 g Fetal heart sounds are audible by an ordinary stethoscope. Lanugo is well formed. Liver and pancreas are functioning. Fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex; urine is present in amniotic fluid. Sex can be determined by ultrasound End of 20th Gestational Week Length: 25 cm Weight: 223 g Spontaneous fetal movements can be sensed by the mother. Antibody production is possible. The hair forms on the head, extending to include eyebrows. Meconium is present in the upper intestine. Brown fat, a special fat that will aid in temperature regulation at birth, begins to be formed behind the kidneys, sternum, and posterior neck. Vernix caseosa begins to form and cover the skin. Passive antibody transfer from mother to fetus begins. Definite sleeping and activity patterns are distinguishable (the fetus has developed biorhythms that will guide sleep/wake patterns throughout life) End of 24th Gestational Week (Second Trimester) Length: 28–36 cm Weight: 550 g Meconium is present as far as the rectum. Active production of lung surfactant begins. Eyebrows and eyelashes become well defined. Eyelids, previously fused since the 12th week, now open. Pupils are capable of reacting to light. When fetuses reach 24 weeks, or 601 g, they have achieved a practical low-end age of viability (earliest age at which fetuses could survive if born at that time), if they are cared for after birth in a modern intensive care facility. Hearing can be demonstrated by response to sudden sound. End of 28th Gestational Week Length: 35–38 cm Weight: 1200 g Lung alveoli begin to mature, and surfactant can be demonstrated in amniotic fluid. Testes begin to descend into the scrotal sac from the lower abdominal cavity. The blood vessels of the retina are formed but thin and extremely susceptible to damage from high oxygen concentrations (an important consideration when caring for preterm infants who need oxygen). End of 32nd Gestational Week Length: 38–43 cm Weight: 1600 g Subcutaneous fat begins to be deposited (the former stringy, “little old man” appearance is lost). Fetus responds by movement to sounds outside the mother’s body. Active Moro reflex is present. Iron stores, which provide iron for the time during which the neonate will ingest only milk after birth, are beginning to be developed. Fingernails grow to reach the end of fingertips End of 36th Gestational Week Length: 42–48 cm Weight: 1800–2700 g (5–6 lb) Body stores of glycogen, iron, carbohydrate, and calcium are deposited. Additional amounts of subcutaneous fat are deposited. Sole of the foot has only one or two crisscross creases, compared with the full crisscross pattern that will be evident at term. Amount of lanugo begins to diminish. Most babies turn into a vertex (head down) presentation during this month End of 40th Gestational Week (Third Trimester) Length: 48–52 cm (crown to rump, 35–37 cm) Weight: 3000 g (7–7.5 lb) Fetus kicks actively, hard enough to cause the mother considerable discomfort. Fetal hemoglobin begins its conversion to adult hemoglobin. The conversion is so rapid that, at birth, about 20% of hemoglobin will be adult in character. Vernix caseosa is fully formed. Fingernails extend over the fingertips. Creases on the soles of the feet cover at least two thirds of the surface ASSESSMENT OF FETAL 31 GROWTH AND DEVELOPMENT Health history McDonald’s rule, a symphysis-fundal height measurement, is an easy method of determining during midpregnancy that a fetus is growing in utero. -over the symphysis pubis at 12 weeks -at the umbilicus at 20 weeks -at the xiphoid process at 36 weeks Nagele’s Rule To calculate the estimated date of birth (EDB)by this rule, count backward 3 calendar months from the first day of a woman’s last menstrual period and add 7 days. Fetal Movement 32 Fetal movement that can be felt by the mother (quickening) occurs at approximately 18 to 20 weeks of pregnancy and peaks in intensity at 28 to 38 weeks at least 10 times a day Fetal Heart Rate Fetal hearts beat at 120 to 160 beats per minute throughout pregnancy. Fetal heart sounds can be heard and counted as early as the 10th to 11th week of pregnancy by the use of an ultrasonic Doppler technique Rhythm Strip Testing. Nonstress Testing. A nonstress test measures the response of the fetal heart rate to fetal movement Vibroacoustic Stimulation. For acoustic (sound) stimulation, a specially designed acoustic stimulator is applied to the mother’s abdomen to produce a sharp sound of approximately 80 decibels at a frequency of 80 Hz, startling and waking the fetus (Chang & Blakemore, 2007) Contraction Stress Testing. ULTRASONOGRAPHY 33 Diagnose pregnancy as early as 6 weeks’ gestation Confirm the presence, size, and location of the placenta and amniotic fluid Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus, anencephaly, or spinal cord, heart, kidney, and bladder defects Establish sex if a penis is revealed Establish the presentation and position of the fetus Predict maturity by measurement of the biparietal diameter of the head Biparietal Diameter 34 Doppler Umbilical Velocimetry Placental Grading. Based particularly on the amount of calcium deposits in the base of the placenta 0 (a placenta 12–24 weeks), 1 (30–32 weeks), 2 (36 weeks), and 3 (38 weeks). Amniotic Fluid Volume Assessment Electrocardiography Magnetic Resonance Imaging Maternal Serum Alpha-Fetoprotein Tripple Screening Chorionic Villi Sampling Amniocentesis Percutaneous Umbilical Blood Sampling Amnioscopy Fetoscopy Biophysical profile  35 PSYCHOLOGICAL AND PHYSIOLOGICAL CHANGES IN PREGNANCY  36 PSYCHOLOGICAL TASKS OF PREGNANCY Narcissism Nest building Ambivalence Introversion Impatience Role-playing  37 Grief Changes that comes with the pregnancy takes mental preparation which may manifest as grief. Narcissism Shift of focus on a different aspect of her life. May also be revealed by changes in activity. Introversion Versus Extroversion Introversion. Turning inward to concentrate on herself. Extroversion. More active, appear healthier than ever before, and are more outgoing. Body Image and Boundary EMOTIONAL The way your body appears to yourself and a RESPONSES zone of separation you perceive between yourself and TO objects or other people. PREGNANCY Stress- brought about by the changes 38 Depression- a feeling of sadness marked by loss of interest in usual things, feelings of guilt or self-worth, disturbed sleep, low-energy and poor concentration. Couvade Syndrome- the Partner experiencing symptoms such as nausea, vomiting, and backache to the same degree or even m ore intensely than their partner. Emotional Lability- mood changes may be connected to narcissism and also can be attributed to hormonal changes. Changes in Sexual Desire– changes may vary throughout the course of pregnancy Changes in Expectant Family- an addition to the family may also affect the first children  39 PRESUMPTIVE SIGN Experienced by the woman but cannot be documented by an examiner PROBABLE SIGNS Objective, so can be VERIFIED by an examiner. Laboratory Test, Pregnancy Test POSITIVE SIGNS True diagnostic findings THE CONFIRMATION OF PREGNANCY  40 REPRODUCTIVE SYSTEM CHANGES UTERINE CHANGES Know your material in advance Anticipate common questions Rehearse your responses Local changes  41 The uterus is more anteflexed, larger and softer to touch than usual  42 Braxton Hicks contractions, serve as warm-up exercises for labor and also increase placental perfusion. BRAXTON HICK’S CONTRACTIONS Ballottement at 16th-20th week  43 CERVICAL CHANGES VAGINAL CHANGES Vaginal secretions during pregnancy fall from a pH of greater than 7 (an alkaline pH) to 4 or 5 (an acid pH)  44 FEEDBACK MECHANISM FROM THE INCREASED ESTROGEN AND PROGESTERONE NO STIMULATION OF FSH AND LH NO OVULATION Changes in the Breasts a feeling of fullness, tingling, or tenderness in her breasts 45 because of the increased stimulation of breast tissue by the high estrogen level in her body. The areola of the nipple darkens, and its diameter increases from about 3.5 cm (1.5 in) to 5 or 7.5 cm (2 or 3 in). forming a secondary areola hyperplasia of the mammary alveoli and fat deposits Montgomery’s tubercles enlarge and become protuberant breasts begin readying themselves for the secretion of milk. By the 16th week, colostrum, the thin, watery, high-protein fluid that is the precursor of breast milk, can be expelled from the nipples.  SYSTEMIC CHANGES 46 Melanocyte-stimulating hormone striae albicantes after birth Vascular spiders or telangiectases Palmar erythema (redness and itching) Melasma or Chloasma INTEGUMENTSRY SYSTEM  47 marked congestion, or “stuffiness,” of the nasopharynx Shortness of breath due to crowding Polyuria result from increased excretion of bicarbonate into the urine to compensate for respiratory alkalosis The total respiratory changes and the compensating mechanisms that occur in the respiratory system can be described a chronic respiratory alkalosis fully compensated by a chronic metabolic acidosis.  48 Cardiovascular Changes Blood loss at a normal vaginal birth is about 300 to 400 mL; blood loss from a cesarean birth can be as high as 800 to 1000 mL Plasma volume increases faster than red blood cell production, the concentration of hemoglobin and erythrocytes may decline, giving a woman a pseudoanemia early in pregnancy Hgb concentration of less than 11 g/100 mL or a hct value below 33% in the first or third trimester of 3rd Trimester- edema and varicosities pregnancy or less than 10.5 1. Enlarged heart on X-ray of the vulva, rectum, and legs due to g/dL (hematocrit 32%) 2nd tri 2. Murmurs pressure on venous flow to the lower is consider ed true anemia 3. Palpitations extremities 49  50 GASTROINTESTINAL CHANGES 1. Nausea and vomiting 2. Heartburn 3. Hemorrhoids 4. Hypertrophy at their gumlines and bleeding of gingival tissue 5. Hyperptyalism due to increased estrogen 6. A lower than normal pH of saliva  51 URINARY CHANGES Urinary changes result from: Effects of high estrogen and progesterone levels Compression of the bladder and ureters by the growing uterus Increased blood volume Postural influences A BUN of 15 mg/100 mL or higher or a serum creatinine concentration greater than 1 mg/100 mL is considered abnormal Creatinine clearance- standard test for renal function during pregnancy.-90 to 180 mL/min  52 a fasting blood glucose level at this time is usually low (80–85 mg/100 mL) 53  54 TERMS TO REMEMBER Chadwick’s sign- Color change of vagina from pink to violet Goodelle’s sign- Softening of the cervix Hegar’s Sign- Softening of the lower uterine segment Ballottement- The fetus can be felt to rise against the abdominal wall upon tapping the lower uterine segment Quickening- Fetal movement felt by a woman Braxton Hicks Contraction- Periodic uterine tightening Linea Nigra- Line of dark pigment that forms on the abdomen Melasma- Dark pigment that forms on face Striae Gravidarum- stretchmarks forming on the abdomen Lightening- The settling of the fetus into the midpelvis  55 ASSESSING FETAL AND MATERNAL HEALTH; PRENATAL CARE HEALTH PROMOTION ND 56 ASSESSMENT BEFORE AND DURING PREGNANCY Prenatal Care  57 PRENATAL CHECKUP Through to 28th week- every 4 weeks After 28th to 36th week- every 2 weeks After 36th week-to delivery- every week Major causes of Serous Illness or Death during pregnancy for women are Health History, hypertension, hemorrhage, embolism, infection, Physical examination, morbid obesity and intra-partum cardiac arrest and obtaining blood and urine samples for laboratory testing  INITIAL INTERVIEW 58 Health History: present and past Demographic Data- name, age, address, telephone number, e-mail address, religion, and health insurance information. Chief Concern- LMP, signs of early pregnancy, (nausea, vomiting, breast changes, or fatigue. ) discomfort (constipation, backache, or frequent urination.), any danger signs of pregnancy such as bleeding, continuous headache, visual disturbances, or swelling of the hands and face. Family Profile- support persons, genetic screening, educational levels and occupation, marital status and support people available as part of the information obtained History of Past Illness- From the information obtained about common infectious diseases and immunizations, you can estimate the degree of antibody protection a woman has against these diseases if she is exposed to them during her pregnancy. Past surgeries are also important to take note. History of Family Illnesses- Ask particularly about renal or cardiovascular diseases, diabetes or cognitive impairment, blood disorders, or genetically inherited diseases. Day History/ Social Profile- current nutrition, elimination, sleep, recreation and interpersonal interactions.  59 Gynecologic History A woman’s past experience with her reproductive system may have some influence on how well she accepts a pregnancy (Menstrual history, age of menarche, usual cycle, ) Perineal and Breast Self-Examination Past Surgery-Tubal surgery, ectopic pregnancy, dilatation and curettage and cervical biopsies. (Cerclage) Reproductive planning Sexual History Stress Incontinence- incontinence of urine on laughing, coughing, deep inspiration, jogging, or running.  OBSTETRIC HISTORY 60  ABO or Rh Incompatibity 61 a positive Coombs test. This is a lab test that looks for the presence of red blood cell antibodies in your baby’s blood. This test is often done after a newborn develops jaundice to figure out the cause. RhIG or RhoGAM Sometimes, an ultrasound is also useful in making a diagnosis of ABO incompatibility, even while the baby is still in the womb. If it’s a severe case of ABO incompatibility, your baby may show ultrasound changes like: Swelling at the back of the neck, head, chest, or belly Pericardial effusion (buildup of fluid around the heart) Increased amniotic fluid Pleural effusion (buildup of fluid around the lungs) A thickened placenta  62 For example, a woman who had term twins, then one preterm infant, and is now pregnant again would be a gravida 3, para 21031 (GTPALM).  63 Review of Systems-Use a systematic approach, such as head to toe, and explain. Interview Conclusion PHYSICAL EXAMINATION 64 Baseline height, weight, prepregnancy body mass index, vital signs, body systems, fundal height measurement (after 12 weeks) and Fetal Heart Sounds 30-40lbs weight gain during pregnancy  65 ASSESSMENT OF SYSTEMS General Appearance and Mental Status Breasts Head and Scalp Heart Eyes Lungs Nose and Sinuses Back Ears Rectum Mouth, teeth, throat Extremities and Skin Neck Lymph Nodes  66 PELVIC EXAMINATION reveals information on the health of both internal and external reproductive organs. a lithotomy position (on her back with her thighs flexed and her feet resting in the examining table stirrups)  67 (girls younger than 14 years are most prone to this difficulty) 68 69 70  71 ESTIMATING PELVIC SIZE 1. The diagonal conjugate. This is the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis If the measurement obtained is more than 12.5 cm, the pelvic inlet is rated as adequate for childbirth (the diameter of the fetal head that must pass that point averages 9 cm in diameter). 2. The true conjugate or conjugate vera is the measurement between the anterior surface of the sacral prominence and the posterior surface of the inferior margin of the symphysis pubis. To do this, subtract 1.5–2 cm from the diagonal conjugate measurement. (the assumed depth of symphysis pubis) The average true conjugate diameter is, therefore, 12.5 cm minus 1.5 or 2 cm, or 10.5 to 11 cm  72 3. The ischial tuberosity diameter. This measurement is the distance between the ischial tuberosities, or the transverse diameter of the outlet (the narrowest diameter at that level, or the one most apt to cause a misfit) It is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus A diameter of 11 cm is considered adequate because it will allow the diameter of the fetal head, or 9 cm, to pass freely through the outlet  73 LABORATORY ASSESSMENT Blood Studies Complete blood count, serologic test for syphilis, blood type and Rh, alpha-fetoprotein, antibody titer against Rh, hepatitis B, rubella, and possibly varicella and HIV Urinalysis Clean catch for glucose, protein, ketones, and culture Tuberculosis PPD test Ultrasound To date pregnancy or confirm fetal health (if date of last menstrual period is unknown) 74  75 SIGNS INDICATING COMPLICATIONS OF PREGNANCY Vaginal Bleeding Persistent Vomiting Chills and Fever Sudden Escape of Clear Fluid From the Vagina Abdominal or Chest Pain Pregnancy-Induced Hypertension Increase or Decrease in Fetal Movement NURSING CARE TO PROMOTE FETAL AND MATERNAL HEALTH Self-Care Needs 1. Bathing 2. Breast Care 3. Dental Care 4. Perineal Hygiene 5. Perineal Hygiene 6. Clothing Sexual Activity Myths about sexual relations in pregnancy that still exist, such as: Coitus on the expected date of her period will initiate labor. Orgasm will initiate preterm labor, but participating in sexual relations without orgasm will not. Coitus during the fertile days of a cycle will cause a second pregnancy or twins. Coitus might cause rupture of the membranes Exercise Walking is the best exercise during pregnancy Swimming may help relieve backache during pregnancy Sleep The optimal condition for body growth occurs when growth hormone secretion is at its highest level—that is, during sleep. This, plus the overall increased metabolic demand of pregnancy, appears to be the physiologic reason that pregnant women need an increased amount of sleep or at least need rest to build new body cells during pregnancy. Pyrosis (heartburn) or dyspnea (shortness of breath) also can cause her to come awake. Employment Travel DISCOMFORTS OF EARLY PREGNANCY: THE FIRST TRIMESTER Breast Tenderness Palmar Erythema Constipation Nausea, Vomiting, and Pyrosis Fatigue Muscle Cramps Hypotension Varicosities Hemorrhoids Heart Palpitations Frequent Urination Abdominal Discomfort Leukorrhea DISCOMFORTS OF MIDDLE TO LATE PREGNANCY Backache Headache Dyspnea Ankle Edema Braxton Hicks Contractions PREVENTING FETAL EXPOSURE TO TERATOGENS A teratogen is any factor, chemical or physical, that adversely affects the fertilized ovum, embryo, or fetus. Strength(radiation), timing(3-8weeks), and affinity to specific tissue (Lead and mercury, attack and disable nervous tissue. Thalidomide, a drug once used to relieve nausea in pregnancy, causes limb defects. Tetracycline, a common antibiotic, causes tooth enamel deficiencies and, possibly, long-bone deformities. The rubella virus can affect many organs: the eyes, ears, heart, and brain are the four most commonly attacked) TORCH Toxoplasmosis, a protozoan infection, through contact with uncooked meat or through handling cat stool in soil or cat litter. - a few days of malaise and posterior cervical lymphadenopathy - infant may be born with central nervous system damage, hydrocephalus, microcephaly, intracerebral calcification, and retinal deformities - Tx;Sulfonamides or Pyrimethamine, an antiprotozoal agent The Rubella virus usually causes only a mild rash and mild systemic illness in a woman, but the teratogenic effects on a fetus can be devastating -hearing impairment, cognitive and motor challenges, cataracts, cardiac defects (most commonly patent ductus arteriosus and pulmonary stenosis), intrauterine growth restriction (IUGR), thrombocytopenic purpura, and dental and facial clefts, such as cleft lip and palate -all pregnant women should avoid contact with children with rashes Cytomegalovirus (CMV), a member of the herpes virus family, is transmitted from person to person by droplet infection such as occurs with sneezing -infant may be born severely neurologically challenged (hydrocephalus, microcephaly, spasticity) or with eye damage (optic atrophy, chorioretinitis), hearing impairment, or chronic liver disease. -The child’s skin may be covered with large petechiae (“blueberry-muffin” lesions Herpes Simplex Virus (Genital Herpes Infection) -The virus spreads into the bloodstream (viremia) and crosses the placenta to a fetus posing substantial fetal risk First trimester--severe congenital anomalies or spontaneous miscarriage may occur. Second or third trimester-- there is a high incidence of premature birth, intrauterine growth restriction, and continuing infection of the newborn at birth. Unless recognized and treated, the fetal mortality and morbidity rates are as high as 80% -Intravenous or oral acyclovir (Zovirax) can be administered to women during pregnancy Other Viral Diseases Syphilis- Treponema pallidum -serologic screening (by either a VDRL or a rapid plasma reagin test) -benzathine penicillin -hearing impairment, cognitive challenge, osteochondritis, and fetal death -newborn with congenital syphilis may have congenital anomalies, extreme rhinitis (sniffles), and a characteristic syphilitic rash -Hutchinson teeth Lyme Disease. a multisystem disease caused by the spirochete Borrelia burgdorferi, is spread by the bite of a deer tick. -typical skin rash, erythema chronicum migrans (large, macular lesions with a clear center), develops. -Pain in large joints such as the knee may develop. - Infection in pregnancy can result in spontaneous miscarriage or severe congenital anomalies. - tetracycline and doxycycline cause tooth discoloration and, possibly, long-bone malformation in a fetus. - course of penicillin will be prescribed to reduce symptoms in the pregnant woman. Live virus vaccines, such as measles, HPV, mumps, rubella, and poliomyelitis (Sabin type), are contraindicated during pregnancy because they may transmit the viral infection to a fetus Other teratogens Alcohol Cigarettes Environmental Teratogens Metal and Chemical Hazards Hyperthermia and Hypothermia Radiation Teratogenic Maternal Stress PRELIMINARY SIGNS OF LABOR Lightening -the settling of the fetal head into the inlet of the true pelvis -on standing she may experience frequency of urination or sciatic pain (pain across a buttock radiating down her leg) from the lowered fetal position. Excess Energy Feeling extremely energetic is a sign of labor important for women to recognize. Slight Loss of Weight Decrease in progesterone initiates increase urine production that can cause up to 1-3 lbs of weight loss. Backache caused by labor contractions Braxton Hicks Contractions towards the end of pregnancy, Braxton HICKS Contractions become stronger Ripening of the Cervix internal sign seen on pelvic examination. Becomes butter-soft and tipped forward. Uterine Contractions True labor contractions usually start in the back and sweep forward across the abdomen like the tightening of a band. They gradually increase in frequency and intensity. Show is the common term used to describe the release of the cervical plug (operculum) that formed during pregnancy. (mucous, often blood-streaked vaginal discharge and indicates the beginning of cervical dilatation) Rupture of the Membranes A sudden gush of clear fluid (amniotic fluid) from the vagina (a danger of cord prolapse and uterine infection) If labor does not spontaneously begin by 24 hours after membrane rupture and the pregnancy is at term, labor will likely be induced. THE NURSING ROLE IN PROMOTING NUTRITIONAL HEALTH DURING PREGNANCY  95 Recommended Weight Gain 11.2 to 15.9 kg (25 to 35 lb) 0.8 kg (1.5 lb) per month during the first trimester 0.4 kg (1 lb) per week during the last two trimesters (a trimester pattern of 4.5-12-12) excessive if over 3 kg (6.6 lb) /month during the 2nd & 3rd trimesters; it is less than usual if it is less than 1 kg (2.2 lb) /month 96  97 COMPONENTS OF HEALTHY NUTRITION FOR THE PREGNANT WOMAN Energy Needs- RDA of calories for women of childbearing age is 2,200. 2,500 for pregnant woman. Protein Needs from 34-46g it increases to 71 g daily. Protein from animal sources provide complete proteins. Fat Needs Omega-3 fatty acids 200-300mg daily. Vegetable oil such as safflower, corn oil, olive, peanut, and cottonseed, fatty fish, omega-3 infused egg, omega-3 infused spreads. Pregnant women should avoid, marlin, orange roughly, tilefish, swordfish, shark, king mackerel and bigeye and yellowfish tuna. Fluid Needs Two or three glasses of fluid daily over and above the three servings of milk recommended by the food pyramid is a common recommendation during pregnancy (a total of six to eight glasses daily)  98 Vitamin Needs  99 Mineral Needs FOODS TO AVOID OR 100 LIMIT IN PREGNANCY Raw eggs and undercooked chicken (salmonella) Soft unpasteurized cheese (listeria) Raw milk Raw seafood and sushi Cold cuts Alcoholic beverages Saccharin Fish with high mercury content Weight loss supplements Caffeine Artificial sweeteners  101 MANAGING COMMON PROBLEMS AFFECTING NUTRITIONAL HEALTH Nausea and Vomiting may be related to: Sensitivity to the high level of chorionic gonadotropin hormone produced by the trophoblast cells High estrogen or progesterone levels Lowered maternal blood sugar caused by the needs of the developing embryo Lack of pyridoxine (vitamin B6) Diminished gastric motility 102 Cravings 103 Pica -from the Latin word for “magpie,” a bird that is an indiscriminate eater) often accompanies iron deficiency anemia Heartburn (Pyrosis) -a burning sensation along the esophagus caused by regurgitation of gastric contents into the lower esophagus. Aluminum hydroxide (Amphojel, Alternagel) Aluminum and magnesium hydroxide (Maalox) Histamine antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) Hypercholesterolemia 104 During pregnancy, increasing progesterone levels cause a further elevation of cholesterol. Combined with intrahepatic cholestasis, this can lead to an increased risk for gallstone formation (cholelithiasis) and cardiovascular disease. Exercising daily Eating oat cereal Broiling meat rather than frying it Using a minimum of salad oils Substituting new omega-3 products in place of butter Eating fish high in omega-3 oil, such as salmon or troutas salmon or trout PROMOTING NUTRITIONAL HEALTH 105 IN WOMEN WITH SPECIAL NEEDS The Adolescent 2500 calories/day Usually deficient in calcium, iron, folic acid, and total calories Advise them to prepare nutritious snacks such as carrot sticks or cheese bites early each day  106 A Woman 40 Years of Age high fluid intake adequate calcium to prevent bone density loss maintaining adequate nutrition during pregnancy, based on these lifestyles A Woman with Decreased Nutritional Store with high parity or a short interval between pregnancies or one who has been dieting rigorously to lose weight before pregnancy Women from low-income families may enter pregnancy with anemia. Women who used diuretics for a dieting program may be deficient in potassium. Women who have been taking oral contraceptives may have decreased folate stores. Women who were using intrauterine devices or who have menorrhagia may be deficient in iron from excessive blood loss with menstrual flows. Women who drink alcohol excessively may be deficient in thiamine A Woman Who Is Underweight 107 10% to 15% less than the ideal weight for her height, or a BMI of less than 18.5 kg/m2 Accompanying iron deficiency anemia. 3500 calories (500 to 1000 calories more than the usual specified daily amount). Being underweight may occur for a variety of reasons: Dieting for weight loss Poverty and the inability to buy adequate food (however, many poor women are obese, not underweight, because starchy foods are less expensive than those that have a higher protein content, such as meat and eggs) Excessive worry or stress, emotions that can lead to a loss of appetite Depression, which causes a chronic loss of appetite An eating disorder, such as anorexia nervosa or bulimia, conditions in which a woman has developed revulsion to food Insufficient intake of food because of chronic poor nutritional habits. A Woman Who Is Overweight 20% above ideal weight or has a BMI over 25 kg/m2. 108 obese if she weighs more than 200 lb, she is 50% above ideal body or her BMI is above 30 kg/m2. increased incidence of gestational diabetes and pregnancy-induced hypertension Hypertension and thrombophlebitis are more likely to occur. difficult to hear fetal heart tones in an obese woman; palpating for position and size of a fetus at birth is also difficult. increased risk for giving birth to infants with macrosomia (excessive fetal growth) this increases the incidence of cesarean births in this population. Performing a cesarean birth, if necessary, may be difficult because of the excessive adipose tissue that must be incised to reach the uterus. Gestational diabetes is more apt to develop postmature infants. Ambulating during pregnancy and immediately afterward is more difficult because of the increased energy expenditure necessary, increasing the risk for complications such as thrombophlebitis and pneumonia. daily caloric intake should not go below 1500 to 1800 per day  109 A Woman Who Is Morbidly Obese over 300 lb or has a BMI over 40 kg/m2 more prone to complications of pregnancy such as gestational or type 2 diabetes, hypertension, back pain, and thrombophlebitis than obese women. prone to sleep apnea so may feel tired over and above normal pregnancy fatigue. Hearing fetal heart sounds and palpating for fetal position can be difficult. Because exercise is difficult, a woman may be prescribed support hose to aid lower leg circulation and help avoid thromboembolitic complications. Pregnancies tend to be prolonged with a high rate of cesarean birth  110 Woman Who Is a Vegetarian lacto-ovo-vegetarians (no animal flesh or fish is eaten, but dairy products and eggs are) lactovegetarians (no meat, fish, or eggs are eaten, but dairy products are) vegans (nothing derived from an animal is eaten) Special concerns for pregnant vegetarians include lack of vitamin B12 (meat is the chief source of this) inadequate intake of calcium (recommend dark-green vegetables as sources) vitamin D (fortified milk and sunlight are the main sources of this) Urge women who are vegetarians to take a daily prenatal supplement, like all women, to ensure adequate iron and folic acid.  111 A Woman With Phenylketonuria Phenylketonuria (PKU) named for the breakdown product of phenylalanine, is an essential amino acid that is excreted in the urine in this form.It is an inherited disorder in which a person cannot convert phenylalanine into tyrosine, the form used for cell growth. Without conversion, phenylalanine accumulates in the person’s blood serum, eventually leaving the bloodstream to invade body cells. When brain cells are invaded, severe cognitive challenge and accompanying neurologic damage, such as recurrent seizures, develop A fetus of a woman with uncontrolled PKU can develop microcephaly, intrauterine growth restriction, and neurologic damage (Poustie, Wildgoose, & Rutherford, 2009). foods low in phenylalanine are fruits and vegetables such as orange juice, bananas, squash, spinach, and peas A Woman With a Multiple Pregnancy 112 a total weight gain of 40-45 lb A Woman Who Smokes or Uses Drugs or Alcohol In addition to specific teratogenic fetal effects, these substances can lead to general nutrition problems because a woman is ingesting these substances rather than eating nutritious foods. A Woman With Concurrent Health Problems Any health concern that requires rigid salt, protein, or carbohydrate restriction poses a potential threat to fetal nutrition during pregnancy. Women who have medical problems such as kidney disease, diabetes, tuberculosis, bulimia, inflammatory bowel disease, celiac disease, or anorexia nervosa should consult their primary care provider before pregnancy because of the specific metabolic disorders that occur with these illnesses. A Woman Who Eats Many Fast-Food Meals 113 Caution women to order hamburgers well done to help prevent Escherichia coli contamination and severe diarrhea, which could lead to a fluid and electrolyte imbalance A Woman With Lactose Intolerance The sugar in milk is lactose. In the intestine, lactose is broken down into glucose and galactose by the enzyme lactase. nausea, diarrhea, cramps, gas, and a general feeling of bloating. Cheese, yogurt, fortified soy milk, lactase tablets can be prescribed to supplement absent lactase. calcium supplement (1200 mg daily) and a vitamin D supplement (400 IU) Because milk is also a good source of protein, be sure to assess whether, without milk, a woman’s intake of protein is adequate A Woman With Hyperemesis Gravidarum 114 sometimes called pernicious or persistent vomiting, is nausea and vomiting of pregnancy that is prolonged past week 12 of pregnancy or is so severe that dehydration, ketonuria, and significant weight loss occur within the first 12 weeks of pregnancy The cause is unknown, but women with the disorder may have increased thyroid function because of the thyroid stimulating properties of human chorionic gonadotropin. Some studies reveal that it is associated with Helicobacter pylori, the same bacteria that cause peptic ulcers elevated hematocrit concentration because of hemoconcentration. Concentrations of sodium, potassium, and chloride may be reduced because of her low intake, and hypokalemic alkalosis may result if vomiting is severe. In some women, polyneuritis, because of a deficiency of B vitamins, develops. Severe weight loss. Urine may test positive for ketones, evidence that a woman’s body is breaking down stored fat and protein for cell growth. intrauterine growth restriction or preterm birth Therapeutic Management. 115 Women with hyperemesis gravidarum usually need to be hospitalized for about 24 hours to monitor intake, output, and blood chemistries and to restore hydration All oral food and fluids are usually withheld. Intravenous fluid (3000 mL of Ringer’s lactate with added vitamin B, for example) may be administered to increase hydration. antiemetic, such as metoclopramide (Reglan), Clear fluids after 24 hrs of no vomiting, then small quantities of dry toast, crackers, or cereal may be added every 2 or 3 hours, then she can be gradually advanced to a soft diet, then to a normal diet. If vomiting returns, total parenteral nutrition will be advised PREPARING A FAMILY FOR CHILDBIRTH AND PARENTING CHILDBIRTH EDUCATION CHILD BIRTH PLAN PRECONCEPTION CLASSES EXPECTANT PARENTING CLASSES SIBLING CLASSES BREASTFEEDING CLASSES  Preparation for Childbirth Classes focus mainly on explaining the birth process rather than pregnancy and ways to prevent or reduce the pain Prenatal Yoga aimed at helping a woman relax and manage stress better for all times in her life, not just pregnancy. Help a woman stay overall fit by their focus on gentle stretching and deep breathing.  Perineal and Abdominal Exercises Supple perineal muscles allow for stretching during birth, reduce discomfort, and help muscles revert more quickly to their normal condition and function more efficiently after childbirth Tailor Sitting Squatting a useful position for second-stage labor, so a woman should also practice this position for about 15 minutes a day Pelvic Floor Contractions (Kegel Exercises) are helpful in the postpartum period to reduce pain and promote perineal healing. Have long term effects of increasing sexual responsiveness and helping prevent stress incontinence Abdominal muscle contractions help strengthen abdominal muscles during pregnancy help prevent constipation as well as help restore abdominal tone after pregnancy. -can also contribute to effective second-stage pushing during labor. - can be done in a standing or lying position along with pelvic floor contractions. - A woman merely tightens her abdominal muscles, then relaxes them. - Blowing a candle - A woman takes a fairly deep inspiration, then exhales normally. Holding her finger about 6 inches in front of herself, as if it were a candle, she then exhales forcibly, pushing out residual air from her lungs as if her finger were a lit candle PELVIC ROCKING helps relieve backache during pregnancy and early labor by making the lumbar spine more flexible. A woman arches her back, trying to lengthen or stretch her spine. She holds the position for 1 minute, then hollows her back. If a woman does this at the end of the day about five times, METHODS FOR MANAGING PAIN IN CHILDBIRTH Most approaches are based on three premises: 1. Discomfort during labor can be minimized if a woman comes into labor informed about what is happening and prepared with breathing exercises to use during contractions. 2. Discomfort during labor can be minimized if a woman’s abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions. 3. Pain perception can be altered by distraction techniques that effectively move a woman’s concentration to other things than pain or by the gating control theory of pain perception The Bradley (Partner-Coached) Method (Robert Bradley) based on the premises that pregnancy and childbirth are joyful natural processes and that a woman’s partner should play an important role during pregnancy, labor, and the early newborn period During pregnancy, a woman performs muscle-toning exercises and limits or omits foods that contain preservatives, animal fat, or a high salt content. She reduces pain in labor by abdominal breathing. In addition, she is encouraged to walk during labor and to use an internal focus point as a disassociation technique. The method is used The Psychosexual Method (Sheila Kitzinger in England during the 1950s) The method stresses that pregnancy, labor and birth, and the early newborn period are some of the most important points in a woman’s life. It includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to “flow with” rather than struggle against contractions (Kitzinger, 1990) The Dick-Read Method (Grantly Dick-Read, an English physician.) The premise is that fear leads to tension, which leads to pain. If a woman can prevent fear from occurring, or break the chain between fear and tension or tension and pain, then she can reduce the pain of labor contractions. A woman achieves lack of fear through education about childbirth and relaxation and reduced pain by focusing on abdominal breathing during contractions (Dick- Read, 1987) The Lamaze Philosophy (Ferdinand Lamaze) a philosophy based on the gating control theory of pain relief. based on the theory that through stimulus-response conditioning, women can learn to use controlled breathing to reduce pain during labor. originally termed the psychoprophylactic method Lamaze preparation is not so much a method to help a woman cope with labor but rather a total philosophy of how to enjoy a safe and satisfying childbirth experience. Throughout the program, six major concepts are stressed: 1. Labor should begin on its own, not be artificially induced. 2. Women should be able to move about freely during labor, not be confined to bed. 3. Women should receive continuous support during labor. 4. No routine interventions such as intravenous fluid are needed. 5. Women should be allowed to assume a nonsupine (e.g., upright or side-lying) position for birth 6. Mother and baby should be housed together following birth, with unlimited opportunity for breastfeeding 1. Women learn in class about reproductive anatomy and physiology and the process of labor and birth in the belief that if women are familiar with what will happen in labor and the nature of contractions, the couple can enter labor with decreased tension. 2. A woman is taught to concentrate on breathing patterns and to use imagery or focusing (concentrating) on a specified object to block incoming pain sensations. The effectiveness of focusing can be observed in athletes who hurt themselves in basketball or football games but do not feel the pain until after the game because they are so focused on winning. 3. Conditioned reflexes, or reflexes that automatically occur in response to a stimulus, can also be used to displace pain during labor. For example, a woman is conditioned to relax automatically on hearing a Three main premises are taught in the command (“contraction beginning”) or at the feel of prenatal period related to the gating a contraction beginning. The responses to contractions control method of pain relief. must be recently conditioned to be effective (because conditioned responses fade if not reinforced Conscious relaxation is learning to relax body parts so that, unknowingly, a woman does not remain tense and cause unnecessary muscle strain and fatigue during labor. She practices this during pregnancy by deliberately relaxing one set of muscles, then another and another until her body is completely relaxed. The Cleansing Breath. To begin all breathing exercises, a woman breathes in deeply and then exhales deeply (a cleansing breath). To end each exercise, she repeats this step. It is an important step to take because it limits the possibility of either hyperventilation or hypoventilation both of which could happen with rapid breathing patterns, and so it helps ensure an adequate fetal oxygen supply. Consciously Controlled Breathing. Using consciously controlled breathing, or set breathing patterns at specific rates, provides distraction as well as prevents the diaphragm from descending fully and putting pressure on the expanding uterus. To practice, a woman inhales comfortably but fully, then exhales, with her exhalation a little stronger than her inhalation (to help prevent hypoventilation). She practices breathing in this manner at a controlled pace, depending on the intensity of contractions. Level 1. Slow chest breathing of comfortable but full respirations at a rate of 6 to 12 breaths per minute. The level is used for early contractions. Level 2. Lighter and more rapid breathing than level 1. The rib cage should expand but be so light the diaphragm barely moves. The rate of respirations is up to 40 per minute. This is a good level of breathing for contractions when cervical dilation is between 4 and 6 cm. Level 3. Even more shallow and more rapid breathing. The rate is 50 to 70 breaths per minute. As the respirations become faster, the exhalation must be a little stronger than the inhalation to allow good air exchange and to prevent hypoventilation. If a woman practices saying “out” with each exhalation, she almost inevitably will make exhalation stronger than inhalation. A woman uses this level for transition contractions. Keeping the tip of her tongue against the roof of her mouth helps prevent her oral mucosa from drying out during such rapid breathing. Level 4. A “pant-blow” pattern, or taking three or four quick breaths (in and out), then a forceful exhalation. Because this type of breathing sounds like a train (breath-breath-breath-huff ), it is sometimes referred to as “choo-choo” or “hee-hee-hee-hoo” breathing. Level 5. Quiet, continuous, very shallow panting at about 60 breaths per minute. This can be used during strong contractions or during the second stage of labor to prevent a woman from pushing before full dilatation a woman traces a pattern on her abdomen with her fingertips The rate of effleurage should remain constant even though breathing rates change. Effleurage serves as a distraction technique and decreases sensory stimuli transmission from the abdominal wall, helping limit local discomfort. Focusing or Imagery. Focusing intently on an object (sometimes called “sensate focus”) to keep sensory input from reaching the cortex of the brain. A woman brings into labor a photograph of her partner or children, a graphic design, or just something that appeals to her. She concentrates on it during contractions. Use of imagery by imagining they are in a calm place such as on a beach watching waves rolling in to them or relaxing on a porch swing Second-Stage Breathing. During the second stage of labor, when the baby will be actually pushed down the birth canal, the type of breathing that is best to use is controversial. In the past, women were told to hold their breath while they pushed. Now it is believed that holding the breath for a prolonged time impairs blood return from the vena cava (a Valsalva maneuver), so this is now discouraged. Based on this, most classes suggest that women breathe any way that is natural for them, except holding their breath during this stage of labor. Women should not practice pushing. The possibility that they could rupture membranes by doing this is too great. They can practice assuming a good position for pushing (squatting, sitting upright, leaning on partner) but should always be cautioned not to actually push during pregnancy.